HIP EXAMINATION

Bone School @ Bangalore

Dr. K.S.MANJUNATH
PROFESSOR AND HEAD OF THE DEPARTMENT OF
ORTHOPAEDICS
BANGALORE MEDICAL COLLEGE AND RESEARCH
INSTITUTE
BANGALORE
Bone School @ Bangalore
 HISTORY
SYMPTOMS / CHIEF COMPLAINTS

• PAIN
• SWELLING
• DEFORMITIES
• LIMP
• STIFFNESS

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 HISTORY
• CHIEF COMPLAINTS
DURATTION
ONSET
PROGRESSION OF THE SYMPTOMS
• PERTAINING TO VARIOUS AETIOLOGY
• CONSTITUTIONAL SYMPTOMS
• COMORBIDITIES
• HABITS
• TREATMENT TAKEN
• OCCUPATION AND RECREATIONAL DEMANDS
• EFFECT ON DAILY ACTIVITIES (ADL)

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 PAIN

• DURATION
• ONSET
• PROGRESSION
• GRADES OF PAIN
• SITE AND NATURE
• CONTINUITY
• REST PAIN
• NIGHT PAIN
( NOCTURNAL PAIN)
• NIGHT CRY

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SWELLING , DEFORMITY , STIFFNES
• DURATION
• ONSET
• PROGRESSION – STATIONARY
INCREASING
REGRESSING

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 LIMP
• DURATION
• ONSET
• PROGRESSION OF LIMP (GRADES)
LIMP WITHOUT AID
LIMP WITH AID
WHEEL CHAIR BOUND
BED RIDDEN

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 SUMMARY OF HISTORY
• ACUTE / CHRONIC
• PROGRESSIVE / NON PROGRESSIVE /
REGRESSIVE
• MONOARTICULAR / POLYARTICULAR
• POSSIBLE AETIOLOGY
(TRAUMATIC/INFECTIVE/INFLAMMATORY/NEO
PLASTIC/DEGENERATIVE/ METABOLIC ETC)
• PATIENT’S DEMAND / EXPECTATION
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 HIP EXAMINATION

LOOK
FEEL
MOVE
MEASURE
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 LOOK
ANTERIOR

LATEAL

ALIGNMENT
POSTERIOR

GAIT

STANDING
ATTITUDE
INSPECTION
SUPINE HIP JOINT
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STANDING POSITION :
ALIGNMENT

FROM THE FRONT

SHOULDER LEVEL
PELVIC
TILT/OBLIQUITY

FROM THE SIDE:

SPINE
PELVIC TILT(FLX/EXT)
HIP (FLX/EXT)
KNEE
(FLX/RECURVATM)

FROM THE BACK

PELVIC TILT
Bone School @ Bangalore GLUTEAL FOLDS
 GAIT

LIMB
TRUNK

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GAIT
POSTRIOR TRUNK BENDING (GLUTEAL LURCH)
Causes : gluteus maximus weakness
Mechanism : to augment hip extension at
terminal stance to accelerate forward

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Causes:
CAUSES:-quadriceps
-QUADRICEPSweakness
WEAKNESS
-EQUINUS DEFORMITY-hip flexor ANTERIOR
-equinus deformity weakness -hip TRUNK
flexionBENDING
contracture
-HIP FLEXOR WEAKNESS
Trunk –hip-knee extended and straight in terminal stance period. The vertical
-HIP FLEXION CONTRACTURE
vector
TRUNK lies posterior
–HIP-KNEE to the
EXTENDED knee
AND axis from
STRAIGHT loading response
IN TERMINAL to preswing
STANCE PERIOD. period-
THE VERTICAL
creating
VECTOR LIES IEM-demanding
POSTERIOR TO THE good
KNEEquadriceps
AXIS FROM power. InRESPONSE
LOADING quadriceps TOweakness
PRESWINGbody
collapses-hence
PERIOD-CREATING the trunk goesGOOD
IEM-DEMANDING for anterior bending
QUADRICEPS to shift
POWER. the vertical vector
IN QUADRICEPS
anteriorBODY
WEAKNESS to theCOLLAPSES-HENCE
knee to balanceTHE TRUNK GOES FOR ANTERIOR BENDING TO SHIFT
THE VERTICAL VECTOR ANTERIOR TO THE KNEE TO BALANCE

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 LATERAL TRUNK BENDING (TRENDLENBURG GAIT)

IN DOUBLE STANCE FORCES

DISTRIBUTED EQUALLY OVER TWO
-
HIPS
IN SINGLE STANCE FORCES INCREASES
6 FOLD BECAUSE
[FORCES OF THE TRUNK NOT
SHARED + WEIGHT OF THE SWING
PHASE LIMB + CONTRACTION OF
ABDUCTORS]
CAUSES: -PAINFUL JOINT DISORDERS
-ABDUCTOR WEAKNESS
-LEVER DISORDERS
-UNEQUAL LEG LENGTH Bone School @ Bangalore
TRENDLENBURG GAIT

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TRENDLENBURG GAIT

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 IN-TOEING GAIT
OUT-TOEING GAIT

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 INSPECTION : SUPINE
LOOK FROM
THE SIDE FOR

Exaggerated lumbar lordosis

Concealed Fixed flexion

deformity

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LOOK FROM PELVIC OBLIQUITY
Concealed FIXED / NONFIXED
THE FRONT ASIS depressed- ASIS elevated-
FOR Fixed ABD def Fixed ADD def

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LOOK FOR APPARENT DFORMITIES @
HIP , KNEE , ANKLE JTS

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LOOK FOR LIMB LENGTH
DESCREPANCY

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 HIP JOINT

• SWELLING / FULLNESS OVER SCARPAS

TRIANGLE
• SINUSES / ULCERS
• PULSATIONS / ENGORGED VESSELS
• FOSSAE AROUND TROCANTER

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FEEL (PALPATION)
WARMTH
WARMTH
JOINT LINE TROCHANTERIC TENDERNESS
TENDERNESS
BI-TROCHANTERIC TENDERNESs
ANTERIOR
SWELLING RETRO-TROCH TENDERNESS

POSITION
LATERAL TROCANTER
SURFACE
THICKNESS(GIRTH)
HEAD OF FEMUR CREPITUS
POSTERIOR POST JOINT
PALPATION
TENDERNESS

SWELLING
MEDIAL
TENDERNESS

PELVIC
TENDERNESS Bone School @ Bangalore
FEEL THE TENDERNESS
ANTERIOR JOINT TENDERNESS TROCHANTERIC TENDERNESS

MID INGUINAL
POINT OEVR THE
2 CM BELOW TROCANTER
AND LATERAL

MEDIAL JOINT TENDERNESS

JUST
BELOW JUST POSTERIOR
MID ING TO
Bone School @ Bangalore ADD. LONG.
POINT FEMORAL PULSE
RETRO-TROCHANTERIC TENDERNESS

MILDLY INT-
ROTATE
POSTERIOR TO
TROCANTER

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 ASSESSMENT OF DEFORMITY

EXAGGERATED
LUMBAR LORDOSIS-
FFD-THOMAS TEST

ASIS –DEPRESSED - SQUARE THE PELVIS

FIXED ABD FURTHER ABD

PELVIC OBLQUITY

ASIS-ELEVATED SQUARE THE PELVIS

FIXED ADD FURTHER ADD

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 HIP EXAMINATION Flexion deformity

THOMAS TEST
NORMAL LIMB

DISEASED LIMB

ONE HAND FEELS THE LORDOSIS

OTHER HAND FLEXES THE NORMAL
HIP TILL THE OBLITERATION OF L.L.
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BILATERAL FFD

FLEX BOTH HIPS TILL THE

L .L. OBLITERATED.

WITH ONE HIP FLEXED,

EXTEND THE OTHER TILL
L.L. REAPPEARS
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Thomas test:
This test is used to
diagnose fixed flexion
deformity of the hip. The
examiner blocks the pelvis by
bringing the contralateral
sound hip into maximal
flexion. This eliminates
lumbar lordosis that can be
used to compensate for the
hip flexion contracture of the
affected hip. The leg to be
examined is then brought into
maximal extension with the
hip in neutral adduction and
rotation.

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FIXED ABDUCTION
Pelvic tilting

Abduction

Pelvis
compensates
by

lowering of the ASIS of

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the diseased side
FIXED ADDUCTION
Pelvic tilting

Adduction

Pelvis
compensates
by

elevation of the ASIS of

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the diseased side
 CORONAL
DEFORMITY
ASIS-ELEVATED - ASIS –DEPRESSED –
FIXED ADDUCTION FIXED ABDUCTION

SQUARE THE PELVIS BY SQUARE THE PELVIS BY

FURTHER ADDUCTION FURTHER ABDUCTION

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FIXED ABDUCTION – ADDUCTION
DEFORMITY

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ROTATION IN HIP EXTENSION

ROTATION IN HIP & KNEE EXTENSION

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ROTATION IN HIP FLEXION

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 MOVE
• FLEXION : 0 – 1200
• EXTENSION : 0 – 200
• ABDUCTION : 0 – 450
• ADDUCTION : 0 – 300
• EXT. ROTATION :
0 – 450
• INT. ROTATION :
0 - 250

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 MOVEMENTS

ACTIVE AND PASSIVE

PASSIVE : RANGE
ASSOCIATED PAIN
MUSCLE SPASM
CREPITUS
INSTABILITY

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FLEXION

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ABDUCTION ADDUCTION

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EXTENSION

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ROTATION IN HIP EXTENSION

ROTATION IN HIP & KNEE EXTENSION

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ROTATION IN HIP FLEXION

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LOWER LIMB TRUE
LENGTH
•TRUE LENGTH
•ANATOMICAL LENGTH
•PATIENT IN STRAIGHAT
LINE AND DEFORMITIES
CORRECTED AND THE
LIMBS ARE KEPT IN
IDENTICAL POSITION
•MEASURED FROM THE
ASIS TO MEDIAL
MALLEOLUS

APPARENT
•APPARENT LENGTH
• FUNCTIONAL LENGTH
•PATIENT IN STRA IGHT LINE
AND LIMBS PARELLEL,
DEFROMITIES NOT CORRECTED
•FROM THE FIXED MIDPOINT
TO THE MEDIAL MALLEOLUS
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 MEASURE
TRUE APPARENT

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 Apparent shortening & lengthening

ADDUCTION  APPARENT SHORTENING

ABDUCTION  APPARENT LENGTHENING

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FEMORAL SEGMENT SHORTENING

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TIBIAL SEGMENT SHORTENING
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BRYANT’S TRIANGLE NELATON’S LINE

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KOTHARI’S LINE SHOEMAKER’S LINE

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TELESCOPY •FLEX THE HIP TO 900
•ONE HAND WITH THE THUMB
ON ASIS AND THE REMAINING
FINGERS OVER THE SOFT
TISSUE PROXIMAL TO FEMUR
•OTHER HAND AT THE DISTAL
FEMUR
•PUSH AND PULL THE FEMUR

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NARATH’S SIGN

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TRENDELENBURG TEST

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TRENDELENBURG TEST

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TRENDELENBURG TEST

• THIS TEST EXAMINE THE STRENGTH OF THE GLUTEUS

MEDIUS. NORMALLY, IN A ONE LEGGED STANCE, THE
PELVIS IS RAISED UP ON THE UNSUPPORTED SIDE. IF
THE WEIGHT BEARING HIP IS UNSTABLE, THE PELVIS
DROPS ON THE UNSUPPORTED SIDE, TO AVOID
FALLING THE PATIENT HAS TO THROW HIS OR HER
BODY TOWARDS THE LOADED SIDE.

• IN THE CLASSIC TEST, THE EXAMINER STANDS The causes of positive

BEHIND THE PATIENT. IF THE PATIENT STANDS ON A Trendelenburg test are:-
HEALTHY HIP THE GLUTEAL FOLD ON THIS SIDE 1.. Weakness of the hip
DROPS. abductors e.g. poliomyelitis
2.. Shortening of femoral neck
• IF THE PATIENT STANDS ON A DISEASED LEG THE e.g. coxa vara.
GLUTEAL FOLD ON THE OPPOSITE SIDE DROPS (THE 3. Dislocation or subluxation
of the hip
SOUND SIDE SAGS).

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bearing
 PIRIFORMIS TEST

• LATERAL DECUBITUS POSITION

•HIP IS FLEXED TO 450
•KNEE IS FLEXED TO 900
•ONE HAND STABILISES THE PELVIS
•OTHER HAND PUSHES THE KNEE ATO THE FLOOR CAUSING THE INTERNAL ROTATION
•PAIN LOCALLY-PIRIFORMIS TENDINITIS
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•PAIN RADIATES DOWN-PIRIFORMIS SYNDROME
 OBER’S TEST

TEST FOR ILEO-TIBIAL TRACT CONTRACTURE

LATERAL DECUBITUS POSITION
KNEE IS FLEXED TO 900
HIP IS ABDUCTED TO 400 AND EXTENDED
WITH THE HIP IN EXTENSION AND KNEE IN FLEXION AND PELVIS IS STABILISED
LIMB IS GENTLY ADDUCTED TOWARDS THE EXAMINING TABLE
NORMALLY THE HIP ADDUCTS AND@ Bangalore
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 PHELPS’ TEST

TO DETECT THE CONTRACTURE OF GRACILIS MUSCLE

PRONE POSITION WITH THE KNEE EXTENDED
PASSIVE ABDUCTION TO THE MAXIMUM WITH THE EXTENDED KNEE
KNEES ARE THEN FLEXED TO RELAX GRACILIS
ATTEMPT TO FURTHER ABDUCT THE HIP WITH KNEE IN FLEXION
FURTHER ABDUCTION IS POSSIBLE IN GRACILIS CONTRACTURE
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 ELY’S TEST

FOR THE CONTRACTURE OF THE RE CTUS FEMORIS

PRONE POSITION WITH THE KNEES EXTENDED
PASSIVELY FLEX ONE KNEE TO BE TESTED
NORMALLY KNEE CAN BE FLEXED FULLY
IN CONTRACTED RECTUS FULL FLEXION OF THE KNEE FO RCES THE HIP INTO FLEXION
CAUSING THE RISE OF BUTTOCKS
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CRAIG’S TEST

FOR ANTEVERSION

1. POSITIONED PRONE
2. KNEE FLEXED 900
3. ONE HAND OVER TROCANTER
4. OTHER HAND IS ROTATING
THE LEG TILL THE TROCANTER
FELT PROMINENT
5. ANGLE SUBTENDED BETWEEN
THE IMAGINARY VERTICAL TO
THE LONG AXIS OF THE LEG

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PATRICK’S TEST

•TEND TO STRESS THE

IPSILATERAL S-I JOINT
•PAIN IS POSTERIOR IN S-I
ARTHRITIS
•PAIN IS ANTERIOR IN HIP
ARTHRITIS

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IMPINGEMENT TEST
FLEXION – ADDUCTION – INTERNAL ROTATION

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 NOT TO FORGET

• OPPOSITE HIP JOINT

• S-I JOINTS
• ILEAC FOSSA
• SPINE
• PER RECTAL EXAMINATION

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THANKS FOR HEARING

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